New Patient Information

Patient Forms

The below patient forms can be completed online prior to your first visit.  Once submitted, your information will be forwarded to our front desk.

• New Patient Forms

Payment and Financing

Our Financial Policy States:

1. With proof of insurance: Primary or secondary, we will bill the insurance for you free of charge. Insurance is filed after services are rendered. After we have received reimbursement from your insurance, you will be billed the remainder. This amount is due 30 days post our statement date.
2. We will file your insurance as a courtesy. In the event your insurance may need additional information, it is your responsibility to respond since any delay will result in a delay of payment.
3. Without insurance: Payment is expected at time services are rendered, unless previous arrangements have been made.
4. In the event an account defaults, all legal and/or processing fees will be added to the unpaid balance and will be the responsibility of the account holder.
5. We accept cash, debit/credit, Mastercard, Visa, Discover, American Express, and CareCredit. There will be a $25.00 fee for all returned checks.

Office Goals and Mission

Thank you for the opportunity to serve you. Customers like you are responsible for our growth and we never forget that fact. If you ever have a question regarding your account or if, for some reason, you are not satisfied, do not hesitate to let us know.

Cancellation Policy:
Our office asks that you provide at least 24 hours advanced notice if you cannot make your scheduled appointment.  A $50 fee will be issued for cancellation without 24 hours notice.
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Patient Confidentiality:
Please be assured that only our billing/credit department uses your personal information and it will be held in strict confidence.

Your Health:
Have you ever been diagnosed with the following conditions:

• Mitral Valve Prolapse?
• Heart Murmur?
• Rheumatic Fever?

Have you ever had:

• Heart Valve Replacement?
• Joint Replacement?
• Cardiac Surgery, within the last year?

If you have answered yes to any of the above health questions, please contact Dr. Cichon prior to making your appointment.
If you have any other questions, please contact our office prior to your appointment.

We look forward to your first visit!